Examining Global Trends of Adolescent Pregnancy: Strategies to Ensure Healthy Sexual Development Presenters Mary E. Dil

1. Examining Global Trends of Adolescent Pregnancy: Strategies to Ensure Healthy Sexual Development Presenters Mary E. Dillon, MSW, Ed.D. Adjunct Professor University of Central Florida School of Social Work Andrew L. Cherry, DSW, ACSW Oklahoma Endowed Professor of Mental Health University of Oklahoma Anne and Henry Zarrow School of Social Work Tulsa

2. (From Bertrand Russell, A History of Western Philosophy, 1954, pp. xiii, 836) The conception of life and the world, which we call “philosophical” are a product of two factors: one, inherited religious and ethical concepts; the other, the sort of investigation which may be called “scientific.”“One of the few unifying forces is scientific truthfulness, by which I mean the habit of basing our beliefs upon observations and inferences as impersonal, and as much divested of local and temperamental bias, as is possible for human beings.”

3. Global Trends of Adolescent Pregnancy in the 21st Century: Implications for Social Work Education • Our students need to know that adolescent pregnancy is a problem in our society because it is a cultural prism. • It exposes a spectrum of harmful sexual and reproductive health issues that are failing adolescents and us as a society. • Adolescent pregnancy is an issue that will be a major health concerns in the 21st century. • Not just because of physiological or developmental health issues but because adolescent pregnancy is a social construct of reality that is described as a problem for the adolescent mother, her child(ren), and the state as a governing political and economic body.

4. Global Trends of Adolescent Pregnancy in the 21st Century • Under most prevailing social systems, policies that control the sexual and reproductive health of girls and women are sustained because they are promoted as being in the best interest of the social order and the state (Stephens, 2004).

5. Is Adolescent Pregnancy a Choice? • Adolescent pregnancy goes far beyond the choices made by adolescent girls; it is a phenomenon that is more associated with structural factors such as the level of national and community wealth and poverty (social capital), conservative tradition and culture, religion, and the political environment. • Based on scientific studies, what becomes evident when examining adolescent pregnancy at the global level, there are three distinct groups of girls who experience pregnancy in very different ways. • The World Health Organization (WHO) defines girls between 10 and 19 years old as adolescents and are from countries that are described by the United Nations as developed, developing, and least developed countries.

6. Global Adolescent Sexual Health • When looking at the reproductive health of adolescents, grouping countries by their stage of economic development has many advantages in studying adolescent pregnancy and childbirth. For one, some 70% of teen births around the world are among girl’s living in developing countries. • In developing countries, where health care is more available, the situation may be quite different. The focus in these countries may be on some aspects of providing adequate medical and social services to reduce adolescent maternal and child risks.

7. Teen Pregnancy in Developed Countries • In developed countries, issues related to adolescent pregnancy are not typically about limited resources to meet the national challenge of adolescent pregnancy. • Here the debate centers on what sexual and reproductive health services that can be provided to adolescents without encouraging higher rates of adolescent pregnancy. • This becomes a conundrum when you are pitting health services against politics and religion. • In some developed countries, questions about public sexual education and the degree to which contraception should be available to adolescents can quickly turn into a raging debate over how young is too young for sexual education and contraception?

8. The Greatest Risks of Adolescent Pregnancy • The greatest risks for an adolescent mother and her child is delaying or failing to receive prenatal care, and the social and political response to her pregnancy. • These are critical issues in all countries, even in developed countries. In developed countries such as the U.S., when pregnant teen are not using prenatal care, the reasons are not related to the lack of available prenatal services, but with the adolescent’s lack of knowledge and the humiliation girls must deal with before asking for prenatal care.

9. The Greatest Risks of Adolescent Pregnancy (cont’d) • In the U.S., some 85% of teen pregnancies are unplanned and 72% receive no prenatal care at all. This is a irrefutable crisis among U.S. teen moms and their children; a crisis that everyone acknowledges and also agrees that it requires a strong public response. • On an intellectual level, there also is agreement that the medical costs related to mothers who do not receive prenatal care far exceed the cost of providing prenatal care. • This begs the question, why are so few pregnant teens receiving prenatal care since there are a number of good professional options available to increase the use of prenatal care among adolescents. What is lacking is a widespread and visible public education campaign in and out of schools.

10. The Greatest Risks of Adolescent Pregnancy (cont’d) • In today’s virtual world, one way to provide healthy reproductive education to adolescent girls is to employ social media in a public campaign that could significantly increase teen use of prenatal care. • Knowing that it is possible to increase utilization, the question is why are there no public campaigns to increase use in the U.S.? • The answer may be framed as a moral issue rather than a medical issue. Even if programs such as Abstinence programs worked, the only thing it would reduce was the rate of adolescent pregnancy, but not the number of teens who do not receive prenatal care. • Unfortunately, the human toll from the lack of prenatal would continue.

11. Brief History of Adolescent Pregnancy • During the 1950’s, teen pregnancy in the United States became one of the few social issues that virtually everyone could agree on…it was a symbol of the deteriorating state of national morality. • At this particular time, adolescent pregnancy was viewed as an individual moral transgression that inflicted harm upon the society at large; therefore it was difficult to try and implement policy and programming to reduce the behavior. • In today’s society, using a failed model based upon a vague moral standard to deliver prevention services typically results in inadequate availability of reproductive and contraceptive health services.

12. Consequences of the Lack of Education • Even in light of a decades-long decline in adolescent pregnancy worldwide, much of the professional literature and almost all of the religious and political rhetoric continues to define adolescent pregnancy as a behavioral problem. • If we base our assumptions on unwed sexual behavior as a moral transgression, how will these failed approaches serve society or the individual in the 21st century? This way of thinking will make it impossible to identify and develop programming to improve the sexual and reproductive health of adolescent girls, boys, and women of childbearing age.

13. Consequences of the lack of Education (cont’d) • In addition to adolescent pregnancy, young girls in the U.S. are at high risk for sexually transmitted infections (STI’s)---including HIV and AIDS---and other sexually related problem. • Why? In large part it is because national sexual education policy does not require programmatic and accurate sexual education in our schools. • When researching adolescent pregnancy worldwide, it was not surprising that U.S. adolescents have some of the highest rates of STI’s, pregnancy, childbirth, and abortion among all developed and many developing nations.

14. Women Lack Adequate Control Over Their Own Reproductive Decisions. • Why the high rates of Adolescent Pregnancy? • Adolescent girls and young women typically lack adequate control over their own reproductive decisions. • If an adolescent mother is expected to lower her health burden, she must be educated about the health and psychosocial implications of adolescent pregnancy and to become empowered by the state to protect herself and her child’s wellbeing. • This said, it is our belief that all young girls and adolescents have an inalienable right to comprehensive education regarding their reproductive health

15. Adolescent Pregnancy Rates Worldwide • Even in light of a decades-long decline in adolescent pregnancy worldwide, much of the professional literature and almost all of the religious and political rhetoric continues to define adolescent pregnancy as a behavioral problems. • This attitude is a failed approach that will not serve society or the individual in the 21st century. • Consequently, when the magnitude and effect of adolescent pregnancy on the individual and community is based on the assumption that unwed sexual behavior among teens is a moral transgression, it will be impossible to identify and develop programming to improve the sexual and reproductive health of adolescent girls, boys, and women of child bearing age.

16. Adolescent Pregnancy: A Social Construct • Adolescent pregnancy, as it is socially constructed in Western culture, has spawned an industry of its own. In developed countries, even as the numbers of adolescent pregnancy drop, adolescent pregnancy prevention organizations continue to dramatize the “problem” and raise money to support their mission—a mission, which supports a vast national and local bureaucracy. • As a global industry, Western prevention and intervention programs for teen pregnancy are the staple of an international cadre of workers who require vast sums of money to promote Western solutions in developing and the least developed nations.

17. Average annual rate of population change for the world and the major development groups

18. Birth rates for women aged 15–19: United States, 1940–2010, and by age, 1960–2010NOTE: Data for 2010 are preliminary.SOURCE: CDC/NCHS, National Vital Statistics System

19. Decline in Teen Births • Fewer babies were born to teenagers in 2010 than in any year since the mid-1940s. • The number of babies born to women aged 15–19 was 367,752 in 2010, a 10-percent decline from 2009 (409,802), and the fewest reported in more than 60 years (322,380 in 1946). • The 2010 total of births to teenagers was 43 percent lower than the peak recorded in 1970 (644,708).

20. This map shows births among adolescent girls 15 to 19 years old as a percentage of total births between 2000 and 2010.

21. Childhood Conditions Correlated with Teen Pregnancy • Over the years research findings about the influence of family, and especially parental influences on the risk of adolescents becoming pregnant has been very consistent.. • Parent/child closeness or connectedness, • Parental supervision or regulation of children’s activities, and • Parents’ values against teen intercourse (or unprotected intercourse) decrease the risk of adolescent pregnancy. • Residing in disorganized/dangerous neighborhoods • Being born into a lower SES family, • Living with a single parent, • Having older sexually active siblings or pregnant/parenting teenage sisters. • Being a victim of sexual abuse • All place teens at elevated risk of adolescent pregnancy.

22. A Teen Mom’s Lack of Social Capital • Studies continue to find that children of socio-economically disadvantaged mothers in general, not just among teenage mothers, affects the child’s development in a similar way. • A teen mother’s lack of socio-economic resources when compared to age of the mother at the birth of her child is more of a detrimental factor in a child’s development of problem behavior than age of the adolescent mother. • Although this does not eliminate the obvious affect of development and immaturity, a mother’s lack of resources increases the risks to her and her child more than an older more mature adolescent mother (Harden, 2007).

23. Adverse Environments and Genetic Liabilities • For example, Rutter (2005) and others suggest that there is a passive gene influence at play that can increase the risk of adolescent pregnancy (passive rGE). He reasons and statistical evidence supports that “Many of the risks deriving from adverse experiences are reliant on nature–nurture interplay” (p. 3). • In other words, this genetic explanation suggests that an adolescent girl’s environmental exposure is related to her genetic liabilities. • In several studies, two sisters, one who gave birth as a teenager and the other who delays childbearing were compared on socio-demographic and child development characteristics. • Among these twins, their age at the birth of their child was statistically less important than the mother’s lack of socio-economic resources in terms of increased risk for her child developing behavioral problems regardless of her age when she gave birth. • Age did not matter when adequate resources were available to the mother and her child(ren).

24. The Gene-Environment Interplay • Several other biological factors are also related to adolescent pregnancy risk. • Timing of pubertal development, hormone levels, and genes are related to adolescent pregnancy risk because of their association with the age of first sexual intercourse. • Among girls, the timing of menarche is a corollary of female biology, inherited genes and environmental exposure. • The most common environmental factor affecting menarcheal age of onset is nutrition. A sufficient body mass index of about 17% body fat is required for menarche to begin. • Puberty takes place over a two to three year time frame.

25. Body Mass Index • While sufficient body mass is needed for menarche to begin, obesity is strongly associated with girls reaching menarche at a significantly earlier age than girls within a normal weight range. • The report by Bau and associates (2009) is representative of the line of research. In the Bau study, girls who were overweight started menarche at 12.5 years of age, while girls within a normal weight range started at age 12.9. Underweight girls started much later at 13.7 years of age. The body weight for all girls was similar irrespective of age and height (Bau, 2009).

26. Sexual Behavior is the most Proximal Determinant of Fertility • What we do know about adolescent sexual behavior, which is of important to our understanding of adolescent pregnancy is that substantial variation in human sexual and reproductive behaviors is inherited. • Explained by evolutionary theory, genetics has a major influence on sexual behavior because sexual behavior is the most proximal determinant of fertility; the evolutionary process by which genic reproduction is modified or maintained.

27. The Genetic Influence • Subsequently, what is most striking about the genetic influence on early fertility is that it accounts for over 50% of the variation in early fertility. • A number of twin studies have shown that twins (monozygotic twins or fertility-related phenotypes) are statistical similar in the ages of menarche, first sex, desired age of marriage and desired age to have children indicating that genetic differences between individual girls account for population variation in sexual timing (Aragona, 2006; Bailey et al. 2000; Dunne et al. 1997; Lyons et al. 2004; Martin et al. 1977; Rowe 2002; Waldron 2004).

28. The Genetic Influence and Sexual and Reproductive Services Provided Children • These finding are important when providing sexual and reproductive services to young girls. • Incorporating an understanding of genetic influences will facilitate the design and delivery of needed services. • The finding are also troubling, however, because the social and emotional cost borne by adolescent girls when genetic influences are ignored. • Costs that too often result in a negative life trajectory for the girls and their children (Kohler, Rodgers & Christensen, 2002).

29. The Belsky-Draper Ho • One of the controversies that erupted in the 1980s was the differential in age between African American and Caucasus girls becoming pregnant in the U. S. • Conservatist where claiming that a break down in traditional catholic sexual morals among African American girls in the U. S. had resulted in the African American girls becoming pregnant earlier and giving birth more often than Caucasus girls. • Rather, Belsky and colleagues (1991; Belsky, 1997) argued that the early family environment, including the infant-parent attachment relationship, conveys to children the risks and uncertainties they are likely to encounter in their lifetimes.

30. The Belsky-Draper Ho(cont.) • According to Belsky, evolutionary theory would predict that this type of information adaptively regulates psychological, behavioral, and reproductive development, either toward a mutually beneficial orientation to interpersonal relations or toward an opportunistic, advantage-taking point of view. • These orientations affect mating behavior, pair bonding, and parental investment; • They are also responsible for earlier or later sexual debut, unstable or stable relationships with intimate partners, and a quantity or quality approach to children and parenting. It was theorized that these divergent developmental trajectories result from an evolutionary response that fit the organism to the environment in ways that enhance reproductive success—or at least did so in the environments of evolutionary adaptation.

31. A Different Evolutionary Explanation • There are several serious flaws in the Belsky-Draper hypothesis. • The most obvious is that the primary worldwide threat to adolescent fertility is inadequate nutrition. In such cases the evolutionary response is to fit the organism to the environment in ways that delay puberty and reduce reproductive success until adequate nutrition is available. • How does an evolutionary response explain precious puberty among African American girls. • A major evolutionary strategy for survival is to increase one’s individual value. For females, when the opportunity to increase social capital is limited and reproductive strategies are the only option available to African American girls, teen pregnancy rates will be high among African American girls. Much like they were between the 1950s and the 1970s in the US.

32. Sexual Education for Young Children • So how can we utilize our knowledge of evolutionary theory and genetics? For one we can address the question of, “How young is too young to begin sexual education?” • This is an honest question given our historical context and the lack of sexual education in the lives most people today. • The answer is that sexual development begins at birth and continues throughout life. Sexual education needs to be aligned with a child’s sexual development. • Just like we teach and educate our child from the time of their birth the individual behaviors and skills needed to prosper and succeed in life; we need to educate children about their bodies and about behaviors that are appropriate and emotionally fulfilling and inappropriate and that could be harmful. • If for no other reason, children need sexual knowledge to better able protect themselves from adults in a highly sexualized global culture.

33. Sexual Education and Opportunity • In addition to sexual education starting at birth, opportunity is the most effective intervention for preventing and reducing teenage pregnancy. Moreover, opportunity drives aspiration. • If you want to know what has caused the great reduction worldwide of teen pregnancy, look at the inverse correlation between the increase in all types of opportunities for girls and women since the 1970s in the US and the 1990s world wide. • Look at the widespread growth of the feminist movement in the U.S. and worldwide between 1970 and 2010.

34. Thanks for listening.